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A nurse is caring for a client who is admitted to the medical-surgical unit.

Exhibits

The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Temperature

Blood pressure

Hemoglobin and hematocrit

WBC count

Stool results

Current medication

Heart rate

Respiratory rate

Answer and Explanation

Correct Answer : B,C,E,F,G

Rationale for correct choices:

Blood pressure: The client’s blood pressure is 90/50 mm Hg, indicating hypotension. This can signal volume depletion or active bleeding, which requires immediate assessment and intervention to prevent shock or organ hypoperfusion.
Hemoglobin and hematocrit: Hemoglobin of 9.1 g/dL and hematocrit of 27% indicate significant anemia, likely from gastrointestinal blood loss. Immediate follow-up is necessary to determine the source and provide interventions such as fluid resuscitation or transfusion.
Heart rate: The client’s heart rate is 118/min, demonstrating tachycardia. This may be compensatory for hypotension or blood loss, suggesting hemodynamic instability and requiring prompt monitoring and intervention.
Stool results: Positive hemoccult indicates gastrointestinal bleeding, which aligns with anemia and tachycardia. Identifying and managing the bleeding source is a priority to prevent further complications.
Current medication: The client takes high-dose ibuprofen (800 mg three times daily), a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs increase the risk for peptic ulcer disease and gastrointestinal bleeding, contributing to the client’s current presentation and requiring immediate provider notification.

Rationale for incorrect choices:

Temperature: The client’s temperature is 37.5° C (99.5° F), slightly elevated but not indicative of infection or immediate risk. Monitoring is appropriate but not urgent.
WBC count: WBC is 6,700/mm³, within normal limits, indicating no current infection or acute inflammatory response. This does not require immediate follow-up.
Respiratory rate: Respiratory rate is 18/min, within normal limits for an adult, and does not indicate acute respiratory distress. Immediate intervention is not necessary.

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Correct Answer is B

Explanation

Rationale:

A. Educate clients who are at risk for Parkinson's disease about maintaining a low-cholesterol diet: This is an example of primary prevention, aimed at reducing risk factors before the onset of disease, rather than tertiary prevention.

B. Provide daily exercise classes to improve ambulation for patients who have Parkinson's disease: Tertiary prevention focuses on managing disease, minimizing complications, and improving quality of life for those already diagnosed. Exercise programs help maintain mobility and prevent further functional decline.

C. Educate clients about common techniques used to diagnose Parkinson's disease: Teaching about diagnostic techniques is related to secondary prevention, which focuses on early detection and timely intervention.

D. Provide screenings for community members to identify early manifestations of Parkinson's disease: Screening is a secondary prevention strategy intended to detect disease early in asymptomatic individuals, not tertiary prevention.

A. The child believes the person will return. B. The child focuses on his own mortality. C. The child refuses to talk about the death. D. The child expresses curiosity about the death process

Correct Answer is A

Explanation

Rationale:

A. The child believes the person will return: Preschoolers view death as temporary and reversible due to their developmental stage and limited understanding of permanence. Magical thinking often leads them to expect the deceased person to come back.

B. The child focuses on his own mortality: This is more typical of older school-age children or adolescents, who have a more developed understanding of death’s permanence and may begin to consider their own vulnerability.

C. The child refuses to talk about the death: Avoidance can occur at any age, but it is not the primary expected response in preschoolers. At this stage, they may ask repetitive questions or make statements that suggest misunderstanding, rather than complete refusal to talk.

D. The child expresses curiosity about the death process: Curiosity about death’s physical aspects is more common in school-age children, who have greater cognitive ability to think concretely about biological processes.

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A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who is admitted to the medical-surgical unit.

Exhibits

The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.